Insurance information

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1 Pediatric Sleep Intake Paperwork Today s date: Completed intake paperwork helps our providers get to know patients and their medical history. We rely on its accuracy and completeness to provide the best care possible. Please take your time and inquire at our front desk or call (907) if you have any questions or are unsure how to complete any section of this form. You can fax this paperwork ahead of time to (907) Your child s name: Date of birth: Parent/guardian name: ailing address: Gender: ale emale Social security number: Relationship: City/State/Zip: Phone: Home obile Work Child s height: Child s weight: Insurance information Primary insurance coverage: Policy number: Policy holder name: Policy holder SSN: Group number: Policy holder DOB: Relationship to patient: Secondary insurance coverage: Policy number: Policy holder name: Policy holder SSN: Group number: Policy holder DOB: Relationship to patient: You can access our patient portal at peakneurology.com and gain full access to your medical history. You can also message your provider, request prescription refills, update your personal information, and recieve a care summary after your visit.

2 Patient intake Who is your pediatrician? Why were you referred to our office? What are your major concerns about your child s sleep? What have you tried to help your child s sleep problem(s)? edical history Please mark any of the following disorders that your child has been diagnosed with: Allergies Asthma Cerebral palsy Chronic bronchitis requent ear infections requent nasal congestion Genetic disease Head/brain injury Hearing problems Heart disease High blood pressure Obesity Obstructive sleep apnea Poor/delayed growth Reflux disease Seizures/epilepsy Sinus problems Speech problems Trouble breathing through the nose Vision problems Please list any other medical problems your child has that are not listed: Psychological history Please mark any of the following disorders that your child has been diagnosed with: Anxiety Autism Behavioral disorder Depression Developmental delay Drug use/abuse Hyperactivity/ADHD Learning disability Obsessive compulsive disorder Psychiatric admission Please list any other psychiatric problems your child has that are not listed: Surgical and major hospitalization history Please list all past surgical operations and/or major hospitalizations by date, operation/illness, and where they occurred. Date Operation/Illness Name of hospital and/or surgeon City and state

3 amily medical history Please list the living status, age, medical problems, and/or cause of death for applicable family members. amily member status Age, now or at a death edical problems Cause of death other ather edication list Please list any medications your child is currenly taking, including medications taken on an as needed basis and supplements/other over the counter medications. edication name Strength/Dose How many, and how often? Substance Tobacco Alcohol Caffiene Social history Does your child use any of the following: Currently use? Previously used? Type Amount per day drinks per week Illicit drugs Is your child exposed to cigarette smoke? drinks per week drinks per day School Performance Has your child ever repeated a grade? Is your child enrolled in special education classes? What grade is your child in? How many school days has your child missed this year? How were your child s grades last year?

4 Sleep History and Symptoms Does your child have regular sleep time? On weekdays On weekends What time does your child go to bed? What time does your child get up in the morning? How many hours of sleep does your child get per night? How many hours does your child nap? Does your child (pleave leave blank if unknown): Have trouble getting up in the morning? all asleep at school? Nap after school or at inappropriate times? Have daytime sleepiness? Have hyperactivity or behavioral problems? Never Sometimes (1-2 times per Routinely (3-5 times per Always (6-7 times per In the past month, have you observed your child: Don t know/ not sure Snoring more than half of observed nights? Always snoring? Snoring loudly? Having loud or heavy breathing? Having trouble breathing or struggling to breath? Stopping breathing during the night? Breathing through their mouth during the daytime? Having a dry mouth when waking up? Wetting the bed? Being hard to wake in the morning? Complaining of headaches in the morning? Appearing to have stopped growing at a normal rate since birth? Seeming to not listen when spoken to directly? Having difficulty with organizing tasks/activities? Appearing easily distracted by external/environmental stimuli? idgeting with hands/feet or squirming when seated? Seeming on the go or appearing as if driven by a motor? Interrupting or intruding on others (such as while talking)?

5 ovement/parasomnia symptoms Does your child: Don t know/ not sure Complain of an uncomfortable feeling in his/her legs(creepy crawly feeling) during the waking hours? Kick his/her legs during sleep? Have nightmares or night terrors? Clench or grind his/her teeth at night? requently wet the bed? Stop breathing during the night? Breathe through their mouth during the daytime? Complain of having a dry mouth when waking up? Walk in his/her sleep? Talk in his/her sleep? Report sudden muscle weakness and/or lose control of his/her muscles with strong emotions? Report an inability to move when falling asleep or waking up? Report vivid dreams just before falling asleep or waking up? Drowsiness rating scale (please indicate chance of your child falling asleep with the given options) (0) chance (1) Slight chance (2) oderate chance (3) High chance Sitting and reading Watching TV or a video Sitting in a classroom at school or during the morning As a passenger in a car or bus for half and hour Lying down to rest or nap in the afternoon Sitting and talking to someone Sitting quietly alone after lunch Sitting and eating a meal EDSS total: Please return forms to front desk once completed.